OBJECTIVE: To explore how contraindications to the use of acupuncture during pregnancy are managed in clinical practice.
METHODS: Acupuncturists' views on their management of threatened miscarriage were sought by using a mixed-methods design involving a self-completed questionnaire and semi-structured interviews. An online survey was distributed through the Australian and New Zealand acupuncture associations requesting practitioners' to access an online link to a questionnaire hosted by Survey Monkey. This questionnaire examined acupuncturist's views on safety and the use of Traditional Chinese Medicine treatment modalities. Descriptive and bivariate statistics were used to analyze data. Thirteen participants were purposefully selected from the survey responses to further explore treatment management. These interviews were recorded via Skype, transcribed, and analyzed by using thematic analysis.
RESULTS: Of 370 respondents, 214 (58%) had treated women for threatened miscarriage within the previous year. Approximately half (58%) had treated four or fewer women, while a minority (14%) had treated 15 or more. The use of abdominal and blood invigorating points reflected diverse treatment strategies within acupuncture textbooks. While the majority avoided acupuncture points traditionally cautioned against in pregnancy, 13% would use LI 4, 22% would use SP 6, and 31% would use BL 32. Two safety themes emerged: "Well I'm safe because…justifying diverse approaches" and "A limited knowledge base-sorting it out for yourself," illustrating how practitioners justified safe practice and had difficulty obtaining trustworthy treatment knowledge.
CONCLUSIONS: Practitioners demonstrated interest in treating threatened miscarriage. All practitioners saw themselves as providing safe treatment. Those using historically contraindicated points justified their use on the basis of personal opinion, advice from trusted others, and clinical experience with a small number of women. In treating at-risk pregnancies, these justifications may be inadequate. Further research exploring the views of practitioners who are experienced in this specialized area would inform clinical practice for this common complication of early pregnancy.
Betts, D. Smith CA, Dahlen H. "Well I'm Safe Because…" - Acupuncturists Managing Conflicting Treatment Recommendations When Treating Threatened Miscarriage: A Mixed-Methods Study.J Altern Complement Med. 2014 Nov;20(11):838-45. To read full text
OBJECTIVE: Threatened miscarriage is a common complication of early pregnancy, which increases the risk of miscarriage or pregnancy complications such as premature birth. Currently there is limited evidence to recommend beneficial medical treatments or lifestyle changes, resulting in a 'watchful waiting' approach. The aim of this study was to describe women's experiences of threatened miscarriage through examining postings to Internet discussion forums.
DESIGN: A Goggle alert for threatened miscarriage was created with emails containing hyperlinks sent to the first author and collected over a seven month period (April to November 2011). Data was analysed using thematic analysis.
FINDINGS: One hundred and twenty one discussion threads were collected. The overarching theme that emerged was one of 'a search for hope and understanding'. Within this there were four sub themes that illustrated this search. 'A reason for hope: stories and real life experiences' illustrated how women sought hope for a viable pregnancy through others. 'Becoming the expert,' captures how women gave advice from their own experiences. 'A safe place to share' and 'connecting to empathic support' illustrates how women used this medium for long distance support.
KEY CONCLUSION: Internet discussion forums were used by women to seek hope and support they were not receiving from their health professionals. Women urged each other to remain hopeful despite a negative medical prognosis. There was an acceptance of a lay expertise within the forums that was valid enough to challenge medical expertise.
IMPLICATIONS FOR PRACTICE: Health practitioners may need education that helps them balance their delivery of medical information with hope in order to increase feelings of trust. With women seeing the Internet as a useful form of support, it may be relevant for practitioners to consider recommending relevant Internet sites and discuss this with women.
Betts D, Smith CA, Hannah DG. 2014 A search for hope and understanding: An analysis of threatened miscarriage internet forums. Midwifery; 30:650–656. Further information
BACKGROUND: Acupuncture is used by nine percent of the Australian population; however, we know relatively little about the practice of acupuncture to treat women's reproductive health in Australia and New Zealand.
METHODS: This study surveyed acupuncturists to examine their practice with treating women's reproductive health complaints. A cross sectional survey of 3406 Australian and New Zealand acupuncturists was conducted. A self-completion questionnaire explored the areas of acupuncture treatment for gynaecological pregnancy and fertility complaints.
RESULTS: Questionnaires were completed by 377 acupuncturists. Ninety-six percent of practitioners reported treating women's reproductive health conditions within the previous year. All three areas of women's reproductive health were commonly treated with 96% treating gynaecological health, 91% treating pregnancy conditions, and 90% fertility conditions. The most commonly treated gynaecological conditions were premenstrual syndrome (90.1%, 95% CI 86.2-93.0), menopause (89.4%, 95% CI 85.4-92.4) and primary dysmenorrhea (89.1%, 95% CI 85.1-92.2). Participants reported treating general fertility not related to assisted reproduction (93%, 95% CI 89.4-95.5), treatment for a diagnosed fertility related conditions (85.8%, 95% CI 81.1-89.4), and to decrease infertility related stress (86%, 95% CI 81.5-89.7). The most common pregnancy related conditions treated were nausea (90.3%, 95% CI 86.3-93.3), back or pelvic pain (89.3%, 95% CI 85.1-92.4), and prebirth labour preparation (86.8%, 95% CI 82.3-90.3).
CONCLUSION: Treating women's reproductive health complaints was commonly reported among the groups of acupuncturists in Australia and New Zealand responding to this survey; however, our findings cannot be generalised to the wider acupuncture communities in these two countries.
Smith CA , Armour M, Betts D. 2014. Treatment of women's reproductive health conditions by Australian and New Zealand Acupuncturists. Complementary Therapies in Medicine. Complement Ther Med. 2014 Aug;22(4):710-8. Further information
BACKGROUND: Threatened miscarriage involves vaginal bleeding in a pregnancy that remains viable. This is a common early pregnancy complication with increased risk factors for early pregnancy loss, preterm premature rupture of membranes (PPROM), preterm delivery, low birth weight babies and maternal antepartum haemorrhage. Currently there are no recommended medical treatment options, rather women receive advice that centres on a 'wait and see' approach. For women with a history of unexplained recurrent miscarriage providing supportive care in a subsequent pregnancy improves live birthing outcomes, but the provision of supportive care to women experiencing threatened miscarriage has to date not been examined.
DISCUSSION: While it is known that 50-70% of miscarriages occur due to chromosomal abnormalities, the potential for therapeutic intervention amongst the remaining percentage of women remains unknown. Complementary and alternative medicine (CAM) therapies have the potential to provide supportive care for women presenting with threatened miscarriage. Within fertility research, acupuncture demonstrates beneficial hormonal responses with decreased miscarriage rates, raising the possibility acupuncture may promote specific beneficial effects in early pregnancy. With the lack of current medical options for women presenting with threatened miscarriage it is timely to examine the possible treatment benefits of providing CAM therapies such as acupuncture.
SUMMARY: Despite vaginal bleeding being a common complication of early pregnancy there is often reluctance from practitioners to discuss with women and medical personal how and why CAM may be beneficial. In this debate article, the physiological processes of early pregnancy together with the concept of providing supportive care and acupuncture are examined. The aim is to raise awareness and promote discussion as to the beneficial role CAM may have for women presenting with threatened miscarriage.
Betts D, Smith CA, Hannah DG. 2012 Acupuncture as a therapeutic treatment option for threatened miscarriage. BMC Complement Altern Med;12(1):20. To read full text
OBJECTIVES: To examine what experienced acupuncture practitioners and researchers considered key aspects of treatment to promote cephalic version for women with a breech presentation, and to establish a treatment protocol through consensus to guide the self administration of moxa by pregnant women.
METHODS AND DESIGN: The Delphi method was used to seek the opinions of key informants. Sixteen English speaking international, Australian and New Zealand acupuncturists working in the area of pregnancy were invited to participate in the study. Participants were given a link to an online survey, and their views sought on treatment parameters guiding the treatment of breech presentation within a research setting.
RESULTS: Two rounds of the Delphi process were undertaken, 12 participants completed round one, and 10 completed round two. Eighty percent of participants agreed that moxa should commence between 34 and 35 weeks gestation. Ninety percent agreed to self administration of moxa by the woman, and use of smokeless and odourless sticks. Seventy percent agreed moxa should be applied for a minimum of 10 days, and be applied once a day for 30min. Monitoring safety was identified as an important outcome. Ninety percent agreed study clinical outcomes should assess side effects including burns, and maternal and foetal outcomes.
CONCLUSION: Findings from our study promote the clinical validity for a future research protocol, and highlight other areas for research to evaluate the role of acupuncture and moxibustion with normalising birth.
Smith CA, Betts D. The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: implications for clinical practice and research. Complementary Therapies in Medicine. 2014 Feb;22(1):75-80. Further informationFurther information
ABSTRACT: Within the acupuncture literature there is debate on the safety of using specific acupuncture points during pregnancy. Termed 'forbidden' or contraindicated, they refer to acupuncture points that can be used to induce labour but may also include points with no known inducing or labour-enhancing effects. Recommendations range from avoiding these acupuncture points at any time in pregnancy to statements that despite the warnings in the literature, these points are not contraindicated during a normal pregnancy. This discussion paper examines the historical use of contraindicated points, the physiology of the pregnant body and the effect of these points during research trials. It is hoped that this will encourage further discussion and provide a background for practitioners to make informed choices about how they use these points in clinical practice.
Betts D. Lennox S. 2011. Forbidden points' in pregnancy: historical wisdom? Acupuncture in Medicine;29 (2):137-9. Further information
Journal of Chinese Medicine 90:20-25 2009
Twenty years ago the treatment principle I would use to induce labour was straightforward – establish contractions. I used strong reducing treatment at acupuncture points indicated for delayed labour, with little underlying diagnostic effort required. The results of this approach were often disappointing; whilst women gave positive feedback, often convinced that the treatment had been successful due to the contractions following treatment, clinical follow up was less encouraging. Their resulting labours were not always efficient and frequently involved medical procedures due to failure to progress, foetal distress or "stuck" babies.
There was thus little advantage for these women in using acupuncture. They may have avoided a medical induction but the resulting labours were not the “natural” births they were planning. My subsequent experience of working with midwives led to a more satisfying approach, one that used acupuncture to correct possible problems, with a focus on promoting an efficient labour rather than merely hastening the onset of contractions. This article discusses this approach, and includes four aspects that I now consider crucial for achieving an optimal outcome – that of natural physiological labour. The latest research on using acupuncture for induction is also discussed, including the implications this has for clinical practice. Further information
Medical Acupuncture. Volume Seventeen / Number Three / May 2006
Background: Midwives in Wellington, New Zealand noted women receiving prebirth acupuncture consistently experienced efficient labours, reporting a reduction in the length of labour and medical intervention, specifically epidurals, medical inductions and caesarean sections.
Objective: To explore this feedback through a naturalistic observational study of midwives who use acupuncture as part of their routine antennal care.
Design, Setting and Patients: Fourteen midwives recorded their acupuncture treatments over a 4 month period. 169 women received treatment.
Main Outcome Measure: The following information was recorded; gestation of women at onset of labour, incidence of medical induction , length of labour, analgesia used and the type of delivery.
Results: When compared to the local regional rate there was a 35% reduction in the number of inductions, (for primigravidea women this was a 43% reduction) and a 31% reduction in the epidural rate. When compared to local midwifery practice there was 32 % reduction in emergency Caesarean Sections and a 9 % increase in normal vaginal births.
Conclusion: Prebirth acupuncture appeared to provide some promising therapeutic results in assisting women to have a normal vaginal birth. A further randomised controlled study is warranted.
Journal of Chinese medicine February 2006
While traditional Chinese acupuncture aims to provide treatment specifically tailored to an individual, the aims of modern research are often different and frequently assess acupuncture formulas for a specific western diagnosis. Despite this conflict, western research into acupuncture presents interesting opportuntities for practitoners. Research appearing in medical and nursing journals can be used to initiate discussion with western health professionals, to promote acupuncture practice and evaluate personal clinical practice. This is especially true in the field of obstetrics where safety and evidence based practice are primary concerns. Further infromation
Journal of Chinese medicine February 2005
Traditional Chinese medicine has very firm ideas on the amount of care and rest appropriate to the first month or longer after childbirththat contrast with the modern emphasis on returning to normal activities within a week or two. Recovery after childbirth can be promoted by appropriate tonifing acupuncture treatments and dietary advice. Furthermore specific problems postbirth, for example persistant uterine bleeding, afterpains, night sweats, perineal discomfort, breast feeding problems and postnatal depression can all be helped with acupuncture. To read full text
Journal of Chinese Medicine October 2004
Pre birth acupuncture refers to a series of treatments in the final weeks of pregnancy to prepare women for childbirth. Research ((Kubista E, Kucera H Geburtshilfe Perinatol 1974; 178 224-9 ) has demonstrated that the mean duration of labour in a group of women giving birth for the first time was reduced from 8 hours 2 minutes in the control group (70 women) to 6 hours 36 minutes in the group of 70 women who had received prebirth acupuncture. In clinical practice acupuncture is an ideal method to help women prepare themselves to have the most efficient labour possible. Feedback suggests that prebirth acupuncture offers a range of positive effects in labour that goes beyond reducing the time spent in labour, with midwives reporting that use of prebirth acupuncture has contributed to a reduced rate of medical intervention in their practice. This article outlines the use of prebith treatments in clinical practice in the hope that this will encourage practitioners to promote this very practical treatment. To read full text
Journal of Chinese Medicine June 2003
Morning sickness is a very common disorder, occurring in up to one half of all pregnancies, and recent research has demonstrated the effectiveness of individualised over simple (Neiguan P-6 only) and sham acupuncture for treating this condition.
Despite this, many acupuncturists express a reluctance to treat morning sickness, voicing concerns over the safety of giving acupuncture treatment in early pregnancy, or past experience of disappointing therapeutic results unless treatment was given more frequently than was practical for the typical western clinic. Hopefully this article will address these concerns and encourage practitioners to actively promote treatment for women experiencing nausea and vomiting in pregnancy. Further infromation
Journal of Chinese Medicine February 2003
Pregnancy-induced hypertension (PIH) is a closely monitored and potentially serious condition, since if it is left untreated there is potential for eclampsia to develop. Although there is little information in the literature on the use of acupuncture to treat PIH, acupuncture can play a major role in its treatment.
This article offers a comprehensive analysis of PIH including the diagnostic and treatment approach of orthodox medicine, Chinese medicine pattern differentiation and treatment by acupuncture, precautions, advice to patients, feedback from midwives who have been successfully treating PIH by acupuncture, and illustrative case histories. Further infromation
Journal of Chinese Medicine February 1999
In my clinical practice I find the use of acupressure provides consistently effective levels of pain relief for women during their labour. Women report a reduction in their pain combined with an overall sense of calmness, as well as a high level of satisfaction with their birth experience. I hope that this article will encourage practitioners to both teach and use acupressure as a birthing tool for labour.